Post by Nursing Board 101 on Aug 18, 2010 13:35:22 GMT -5

1. The nurse is preparing to move an adult who has right-sided paralysis from the bed to the wheelchair. Which statement describes the best action for the nurse to take?a. position the wheelchair on the left side of the bedb. keep the head of the bed elevated at 10o c. protect the client’s left arm with a sling during the transferd. bend at the waist while helping the client into a standing positionANSWER A: Place the wheelchair beside the bed, on the client’s strongest side so that it faces the foot of the bed. The head of the bed should be in an upright position. There is no need to place special protection to the unaffected arm during the transfer. The nurse should always bend at the knees not at the waist.

2. Which statement by the nurse best indicates a correct understanding of “log rolling” when moving a client?a. one nurse may perform this task aloneb. pillows are needed for positioning in order to provide supportc. the legs should be moved before the head is movedd. keeping the neck in a straight position is the primary concernANSWER B: A pillow should be placed between the knees/legs for support while the client is being turned. It takes two or three nurses to do log rolling. The whole spinal column should be kept straight and the entire body moved at once.

3. The nurse is caring for a client who has temperature of 105oF (40.50C). The physician orders the application of a cooling blanket. The nurse should know that which of the following statements is true about the use of a cooling blanket?a. cold application will increase the metabolic rateb. vital signs should be monitored every 8 hoursc. the client should remain in one position to conserve energyd. skin hygiene and protection of body surface areas is essentialANSWER D: Cold application lowers the metabolic rate and causes vasoconstriction in the area. Therefore, assessment of the skin, protection of the skin surfaces with oil, and repositioning are all vital to prevent skin breakdown. The temperature will be monitored continually with a rectal probe and blood pressure, pulse, and respirations will be monitored frequently.

4. The nurse is preparing to administer a sponge bath to an infant with a high fever. Administration of the bath should include:a. large amounts of alcohol to increase evaporation of heatb. adjustment of the water temperature to 60-70 0Fc. wet clothes applied to all areas where blood circulates close to skin surfacesd. small areas of the body sponged at a time to avoid rapid heat lossANSWER C: Wet clothes should be applied to forehead, ankles, wrists, axilla and groin. These are the areas where blood circulates closest to the skin surface. If alcohol is used, small amounts are indicated. Large amounts of alcohol are very drying to the skin and toxic to inhale. The temperature should be 85-100 degrees F. Rapid heat loss is desired so large areas of body are sponged.

5. The nurse is instructing the family of a homebound bedridden client in the general prevention of pressure sores. Measures to include in the teaching include:a. promoting lifting rather than dragging when turning the clientb. massaging directly over pressure sitesc. changing the client’s position every 4 hoursd. cleaning soiled areas with hot waterANSWER A: Promoting lifting rather than dragging when turning or moving the client will reduce friction and shearing. This will assist in preventing pressure sores. The caregiver should massage around but not directly over pressure sites. The client’s position should be changed every 2 hours. Soiled areas should be cleaned with warm not hot water.

6. Which of the following findings would the nurse note when assessing a client with Stage I pressure ulcer? The ulcer displays:a. superficial skin breakdown c. subcutaneous damage or necrosisb. deep pink, red, or mottled skin d. damage to muscle or boneANSWER B: Stage I pressure ulcers show discoloration of skin to deep pink, red or mottled appearance. Temporary blanching of the area from pressure can last several minutes due to poor circulation in the area. Choice I, superficial skin breakdown, is a characteristic of stage II. Choice 3, subcutaneous damage or necrosis is a characteristic of Stage II pressure ulcer. Choice 4, damage to muscle or bone, is characteristic of a stage 4 pressure ulcer.

7. An adult has developed a Stage II pressure ulcer. He is scheduled to receive wet to dry dressings every shift. The nurse realizes that the purpose of receiving this type of dressing is to:a. draw in wound exudate and decrease bacteriab. debride slough and escharc. promote healing by gas exchanged. promote a moist environment and soften exudateANSWER B: In a wet to dry dressing, the wet gauze dressing either covers the wound or is packed into the wound and is covered with a dry dressing. The dry layer creates a wick and pulls moisture from the wound, thus debriding slough and bacteria. Answer A is not correct because the exudate ids drawn out not in.

8. The nurse is performing a wound irrigation and dressing change. Which action, when taken by the nurse, would be a break in the technique?a. consistently facing the sterile fieldb. washing hands before opening the sterile setc. opening the bottle of irrigating solution and pouring directly into a container on the sterile fieldd. opening the sterile set so that the initial flap is opened away from the nurseANSWER C: After opening a sterile bottle the edge of the bottle is considered to be contaminated. The nurse should pour a little solution out first to wash away organisms on the lip of the opening and then pour from the same side of the bottle into the sterile container on the sterile field. The nurse should always face the sterile field. Hands should be washed before opening the sterile set. The sterile set should be opened so that the initial flap is opened away from the nurse. This means that the final flap will be opened toward the nurse and the nurse will be opened toward the nurse and the nurse will not have to reach across the sterile field.

9. Total Parenteral Nutrition (TPN) is ordered for an adult client. The nurse expects the solution will contain all of the following nutrients except:a. dextrose 10% c. electrolytesb. trace minerals d. amino acidsANSWER A: The conc. of dextrose in TPN solutions is at least 30 % Trace minerals such as zinc, copper, chromium, and manganese are usually added. Electrolytes and amino acids are part of TPN solutions.

10. The nurse caring for an adult client who is receiving TPN will need to monitor him for which of the following metabolic complications:a. hypocalcemia and hypercalcemia c. hyperglycemia and hyperkalemiab. hyperglycemia and hypokalemia d. hyperkalemia and hypercalcemiaANSWER B: Metabolic complications from administration of TPN include hyperglycemia, hypoglycemia, hypocalcemia, hypokalemia, hypomagnesemia, hyponatremia and hypophosphatemia. Hyperglycemia is the most common complication of TPN. Hypoglycemia can occur when TPN is suddenly withdrawn. Electrolyte deficiencies can occur. The addition of electrolytes is individualized based on the client’s metabolism and on the underlying condition.

11. The nurse is caring for a client who is receiving IV fluids. Which observation the nurse makes best indicates the IV has infiltrated?a. pain at the siteb. a change in flow ratec. coldness around the insertion siteANSWER C: Coldness and swelling around the insertion site are the best indicators that the fluid has infiltrated into the subcutaneous tissue. Pain at the site can be a sign of phlebitis. A change in the flow rate can also be a sign of an infiltrated IV. Redness around the insertion site is a sign of phlebitis.

12. Within 20 minutes of the start of transfusion, the client develops a sudden fever. The most appropriate initial response by the nurse is to:a. force fluids c. increase the flow rate of IV fluidsb. continue to monitor the vital signs d. stop the transfusion ANSWER D: Sudden development of fever during a blood transfusion may be indicative of a pyrogenic reaction. The most appropriate nursing action is to discontinue the blood flow to prevent a more severe reaction. The nurse will continue to monitor the vital signs; however this is not the initial action. Forcing fluids and increasing the flow rate of IV fluids may be appropriate at a later time if hypotension occurs.

13. The nurse is caring for a client who has had a chest tube inserted and connected to water seal drainage. The nurse determines the drainage system is functioning correctly when which of the following is observed?a. continuous bubbling in the water seal chamberb. fluctuation in the water seal chamberc. suction tubing attached to a wall unitd. vesicular breath sounds throughout the lung fieldsANSWER B: Fluctuation in the water seal chamber demonstrates that the tubing system is patent. Bubbling in the water seal is normal only if it is gentle and occasional. Vigorous bubbling indicates that air is being pulled into the system and is not normal. The fact that suction tubing is attached to a wall unit provides no information about function. Vesicular breath sounds should not be heard in the upper chest.

14. The nurse is caring for a client who has just had a chest tube attached to a water seal drainage system. To ensure that the system is functioning effectively the nurse should:a. observe for intermittent bubbling in the water seal chamberb. flush the chest tubes with 30-60 ml of NSS every 4-6 hoursc. maintain the client in an extreme lateral positiond. strip the chest tubes in the direction of the clientANSWER A: Intermittent bubbling in the water seal chamber indicates that air is leaving the thoracic cavity. If there is no bubbling in the water seal chamber, it indicates either obstruction of the tubing or reexpansion of the lungs. Reexpansion of the lung is unlikely, as the tube has just been inserted.

15. The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to:a. notify the physicianb. insert a new chest tubec. cover the insertion site with petroleum gauzed. instruct the client to breathe deeply until help arrivesANSWER C: Covering the insertion site with petroleum gauze is a priority nursing measure that prevents air from entering the chest cavity. Notifying the physician should be done after covering the insertion site. Inserting a chest tube is not a nursing action. Instructing the client to deep breathe will cause air to enter the chest cavity.

16. A patient is ordered oxygen via nasal prongs. The nurse administering oxygen via this low-flow system recognizes that this method of delivery:a. mixes room air with oxygenb. delivers a precise concentration of oxygenc. requires humidity during deliveryd. is less traumatic to the respiratory tractANSWER A: Low-flow oxygen systems provide an oxygen concentration that is determined by the amount of air drawn into the system and the dilution of oxygen from room air. There is a considerable variation in the concentration of oxygen that can be delivered to the client. Not all systems require humidification. Oxygen therapy given in short-term basis is usually not traumatic to the respiratory tract.

17. An adult is receiving oxygen by nasal prongs. Which statement by the client indicates that the client teaching regarding oxygen therapy has been effective?a. “I was feeling fine so I removed my nasal prongs.”b. “I’ve increased my fluids to six glasses of water daily.”c. “Don’t forget to come back quickly when you get me out of bed; I don’t like to be without my oxygen for too long.”d. “My family was angry when I told them they could not smoke in my room.”ANSWER D: Oxygen is a flammable gas and smoking is not permitted in the area. Compliance with the prescription for oxygen therapy is extremely important to prevent the fluctuation of oxygen levels.

18. An adult client has a nasogastric tube in place to maintain gastric decompression. Which nursing action will relieve discomfort in the nostril with the NG tube?a. remove any tape and loosely pin the tube to his gownb. lubricate the NG tube with viscous xylocainec. loop the NG tube to avoid pressure on the naresd. replace the NG tube with a smaller diameter tubeANSWER C: Looping the NG tube will prevent pressure on the nares that can cause and eventual necrosis. Pinning the tube to the client’s gown would cause irritation of the nares each time he moved and might cause dislocation of the tube.

19. An adult client has just returned to his room following a bowel resection and end-to-end anastomosis. The nurse can expect the drainage from the NG tube in the early post-op period to be:a. Clear c. Scantb. Mucoid d. DiscoloredANSWER D: The drainage following abdominal surgery is discolored as it is evacuating stomach and intestinal contents, not mucoid material. There is a significant amount of drainage.

20. The physician inserts a central venous catheter; the nurse should assist the client to assume which of the following positions?a. supine c. reverse trendelenburg’sb. trendelenburg’s d. high fowler’sANSWER B: The client is placed in Trendelenburg position to aid in the filling of the subclavian veins. The rest do not.

21. The major dietary treatment for ascites calls for:a. high protein c. restricted fluidsb. increased potassium d. restricted sodiumANSWER D: Sodium restriction is most important for a client with cirrhosis because fluid retention contributes to ascites. A high protein diet is contraindicated because increased protein in the intestine causes elevated ammonia levels. The diseased liver is unable to convert ammonia to urea, thereby leading to possible signs of hepatic encephalopathy. Increased potassium would not be indicated because advancing cirrhosis could lead to hepato-renal disease with resultant renal retention of potassium. Fluids would probably be restricted but sodium restriction is more important.

22. The nurse is to give medication to an infant. What is the best way to assess the identity of the infant?a. ask the mother what the child’s name isb. look at the sign above the bed that states the client’s name c. compare the bed number with the bed number of the care pland. compare the ankle band with the name on the care planANSWER D: Making sure that the client’s name is the same as the name on the medication plan is the only safe way to administer the medications

23. The nurse is caring for a client who has been placed in cloth wrist restraints. To ensure the client’s safety, the nurse should:a. remove the restraints every 2 hours and inspect the wristsb. wrap each wrist with gauze dressing beneath the restraintsc. keep the head of the bed flat at all timesd. tie the restraints using a square knotANSWER A: Wrists must be inspected for signs of skin breakdown or trauma. B, wrist restraints are soft and padded already; no further padding is necessary. C, position of the bed has no relationship to safety with use of restraints. D, Method for tying restraints is important for ease of removal, but does not in itself, affect safety.

24. The nurse is preparing a client for IVP tomorrow. The client ells the nurse that she gets a rash and becomes short of breath after eating lobster. Given this information, the nurse knows that the client:a. should be visited by a dietitian while in the hospitalb. is not a candidate for IVPc. is at risk for an allergic reactiond. will require an antihistamine before her IVPANSWER C: People who are allergic to shellfish, iodine, are at risk for allergic reactions to the contrast material iodine, used for an IVP.

25. The nurse is caring for a client who is to have a lumbar puncture. How should the client be positioned during the procedure?a. prone with head turned to the leftb. side lying in a fetal positionc. sitting at the edge of the bedd. Trendelenburg positionANSWER B: The fetal position, fetal, increases space between lumbar vertebrae facilitating easier entry of the needle into the subarachnoid space.

26. An adult client has a central line placed for IV fluids. When the nurse enters the room the IV bag is dry, the IV line is full of air, and the client is dyspneic. What is the best initial nursing action?a. notify the physician and administer oxygen via nasal cannula immediatelyb. hang another IV bag as soon as possible, then remove the air from the IV linec. clamp the tubing and place the client on the left side with head downd. begin CPR and call the code teamANSWER C: Air embolism occurs frequently with central lines with sudden onset of dyspnea, hypotension, chest pain, and cyanosis. The best initial nursing action is to clamp the IV line and turn the client to the left side to trap the air in the right side of the heart so it does not enter the pulmonary artery. Then call the physician and administer oxygen.

27. An adult client is to receive a unit of whole blood. The client’s vital signs before starting the transfusion are BP 120/70, P 80, and T 98.40F. Five minutes after the transfusion was started the vital signs are BP 100/70, P100 and T 99.40F. What should the nurse do initially?a. slow down the rate of the transfusion, reassess the client in 15 minutesb. stop the transfusion, keep vein open with normal salinec. slow down the infusion, notify the physician immediatelyd. administer acetaminophen (Tylenol), continue to monitor closely throughout the transfusionANSWER B: The symptoms suggest transfusion reaction. The priority nursing action for a client with symptoms of an acute hemolytic reaction to a blood transfusion is to stop the transfusion immediately. Other signs suggesting transfusion reaction include chills, increased respiration, flushing, low back or thigh pain, headaches, pleuritic chest pain, dyspnea and abnormal bleeding, hemoglobinuria and shock.

28. The nurse is administering medication in an extended care facility. What is the best way for the nurse to correctly identify the client before administering the medications?a. check with picture identification on the fileb. check the arm bandc. check the name on the bedd. check the name on the room doorANSWER A: Having a picture ID for each resident allows the nurse to positively identify the client. This helps to decrease errors in a population that may not always be able to respond appropriately.

29. A client is scheduled to undergo an exploratory laparotomy in one hour. The nurse has just received the order to administer his pre-operative medication. What assessment is essential for the nurse before administering the medication?a. the client’s ability to cough and deep breatheb. any drug hypersensitivity or allergyc. the patient's understanding of the surgical procedured. whether patient's family is present and supportiveANSWER B: A complete drug history on every perioperative client is essential because of potential reactions to drugs. Drug hypersensitivity and allergic reactions must be assessed before preoperative medications are administered.

30. An adult client has been on bed rest for several months. Which statement best describes the relationship between complications of prolonged bed rest and nursing interventions to prevent these complications?a. turning and positioning will help decrease the potential for calcium loss from bonesb. adequate fluid intake is vital to decrease the risk of brittle bonesc. leg exercises are important to decrease the loss of calcium from the bones and the risk of pathological fracturesd. encouraging milk intake will help decrease the loss of calcium from the bonesANSWER C: Leg exercises are important to help prevent calcium loss from the bones. The ideal exercises will have some resistance or weight bearing as tolerated.

31. The nurse is inserting an indwelling urinary catheter. Which action is essential to decrease the complications associated with catheter insertion?a. cleanse the female client using betadine-soaked 4x4’s, cleaning from the rectal area to the clitorisb. utilizing a catheter that is slightly larger than the external urinary meatusc. utilize clean techniqued. test the retention balloon prior to insertionANSWER D: The balloon should be checked for inflation and leaks prior to insertion, preventing repeated catheterization if the balloon fails.

32. The nurse is caring for an adult client who is scheduled for an intravenous pyelogram (IVP). Which nursing intervention is essential?a. encourage large amounts of fluids prior to the testb. assess for any indications of allergiesc. administer a laxatived. restrict fluids only in clients with marginal renal reserve or uncontrolled diabetesANSWER B: The client should be assessed for allergic reactions to iodine shellfish allergy or previous allergic reaction to contrast dye materials.

33. The nurse is caring for a client who has a nasogastric tube attached to low wall suction. The suction is not working. Which is the nurse least likely to note when assessing the client?a. client vomitsb. client has a distended abdomenc. there is no nasogastric output in the last two hoursd. large amounts of nasogastric outputANSWER D: If the nasogastric suction is not working, the nurse would not expect to see large amounts of nasogastric output.

34. A client who has ascites is admitted to the hospital and will be undergoing a paracentesis. What should be included in the nursing care plan?a. monitor client closely for evidence of vascular collapseb. place client in Trendelenburg position for the procedurec. encourage client to drink plenty of fluids to distend the bladder prior to the procedured. have client remain on bed rest for 24 hours following the procedureANSWER A: Removing large amounts of fluid may cause hypotension leading to vascular collapse. The client should be monitored closely for decrease in blood pressure, increase in pulse and pallor.

35. A patient underwent an exploratory laparotomy two days ago. The physician has just written an order for a soft diet. The nurse assessed the client and did not hear bowel sounds in any quadrant. What is the best nursing action?a. follow the physician’s order and feed the clientb. cancel the physician’s order and make the client NPOc. order clear liquids for the clientd. notify the physician that the client does not have bowel sounds at this timeANSWER D: Solid food should not be given until the client has bowel sounds. The nurse should notify the physician of the assessment findings prior to feeding this client.

36. Your patient is receiving O2 at 2 liters per nasal cannula. His roommate lights a cigarette and tosses the match catching the curtain on fire. What is the priority action for the nurse?a. turn off the oxygen c. try to extinguish the fireb. sound the fire alarm d. remove the clients from the roomANSWER A: Oxygen itself does not burn, but supports combustion, so a fire burns more readily in the presence of oxygen. If the client is not engulfed in flames, the nurse’s priority action should be to turn off the oxygen.

37. An 84-year-old male patient has been bedridden for two weeks. Which of the following complaints by the patient indicates to the nurse that he is developing a complication of immobility?a. stiffness of the right ankle joint c. short term memory lossb. soreness of the gums d. decreased appetiteANSWER A: Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy.

38. Which of the following nursing interventions indicate an understanding on the part of the nurse concerning proper care of pressure ulcers?a. rub reddened skin to increase circulationb. use a heat lamp 4 times a day to dry the wound surfacec. cleanse a non-infected pressure ulcer with isotonic salined. cleanse a non-infected pressure ulcer with povidone-iodineANSWER C: A noninfected pressure ulcer should be cleansed gently with a non-ionic cleanser such as isotonic saline to prevent disruption of healing.

39. A client has been placed in blood and body fluid isolation. The nurse is instructing auxiliary personnel in the correct procedures. Which statement by the nursing assistant indicates the best understanding of the correct protocol for blood and body fluid isolation?a. masks should be worn with all client contactb. gloves should be worn for contact with non-intact skin, mucous membranes or soiled itemsc. isolation gowns are not neededd. a private room is always indicatedANSWER B: Gloves should be worn for all contact with blood and body fluids, nonintact skin and mucous membranes; for handling soiled items, and for performing venipuncture.

40. A female client will have to change the dressing on her injured right leg twice a day. The dressing will be a sterile dressing, using 4x4’s, normal saline irrigant, and abdominal pads. Which statement best indicates that the patient understands the importance of maintaining asepsis?a. “If I drop the 4x4’s on the floor, I can use them as long as they are not soiled.”b. “If I drop the 4x4's on the floor, I can use them if I rinse them with sterile normal saline.”c. “If I question the sterility of any dressing material, I should not use it.”d. “I should put on my sterile gloves, then open the bottle of saline to soak the 4x4’s.”ANSWER C: If there is ever any doubt about the sterility of an instrument or dressing, it should not be used.

41. Which of the following nursing interventions would the nurse perform prior to administering a tube feeding?a. check for placement by aspirating for gastric contents with a syringe and test pH with Testapeb. advance the tube 3-5 inches prior to the feedingc. instruct the client to swallowd. instill 30 ml of sterile water into the tubeANSWER A: Prior to administering a tube feeding the nurse must check for placement of the tube in the stomach. The most effective methods include; aspirating for gastric contents with a syringe and testing pH with testape and placing the stethoscope over the stomach and rapidly injecting 5-10 ml of air through the tubing. A swooshing sound is heard as the air enters the stomach.

42. An adult client is being treated in the burn unit for partial and full-thickness burns of the left foot, ankle, and leg. Skin autographs are taken from the right thigh and a skin graft is performed. The nurse planning care for the client on return from the operating room includes which of the following nursing interventions?a. change dressing on graft sites every shiftb. cover donor site with fine mesh gauze and expose to airc. lubricate donor site with skin cream every shiftd. hydrotherapy to graft sites dailyANSWER B: The donor site may be treated in a variety of ways but the most common method is to cover the wound with a fine mesh gauze or an impregnated gauze that is opened to the air or exposed to a heat lamp to allow the wound to dry.

43. The nurse is caring for a client who is being transfused for severe gastrointestinal bleeding. The nurse can decrease the danger of hypothermia by:a. administering blood with normal salineb. administering blood products through a central linec. giving only packed cellsd. warming blood to body temperature before administeringANSWER D: Hypothermia with cardiac arrhythmias may occur when infusing the large quantities of blood needed in GI bleeding. Blood warming equipment should be used to prevent this problem.

44. The mother of a three-year-old child calls the clinic and states that her child has just swallowed an unknown amount of baby aspirin. What is the best initial action for the nurse to take?a. call the physicianb. instruct the mother to bring the child to the emergency room as soon as possiblec. discuss with the mother observable changes for which she should watch the childd. tell the mother to give ipecac to the child and then come to the emergency roomANSWER D: The first line of treatment is ipecac. The child should be seen as possible after that. The child has just swallowed the aspirin and is not described as being unconscious. Ipecac is contraindicated if the child is unconscious.

45. A 56-year-old is admitted to the burn unit with partial and full-thickness burns of both legs, which occurred when a charcoal grill tipped over on her. The burn area is edematous. Blister formation and a large amount of fluid exudate is noted. Urine output is 30 ml per hour, BP 90/60, and pulses 110. A primary nursing diagnosis during the initial 48-72 hours following the burn is:a. body image disturbance related to disfiguring burns of both legsb. high risk for infection related to skin breakdownc. potential for ineffective airway clearance related to smoke inhalationd. fluid volume deficit related to increased capillary permeabilityANSWER D: Since this client is not at high risk for pulmonary complication (her burns are lower extremity and occurred outdoors), the most urgent need is to replace lost fluids and prevent irreversible shock. The first 48-72 hours after the burn is characterized by a rapid shift of fluids from the vascular compartment into the interstitial spaces as a result of vasodilation and increased capillary permeability.

46. While assessing the client with burns on the back and trunk, the nurse notes areas that are not painful, grayish–white in color, and leathery in appearance. The nurse documents that these burns are:a. superficial burns c. deep partial thickness burnsb. superficial partial thickness burns d. full thickness burnsANSWER D: Full-thickness burns destroy the epidermis. The nerve ending are destroyed, resulting in a painless wound that appears dry, pale, and leathery and ranges from white to charred in appearance.

47. An adult is scheduled for IVP. Before sending her to have the test the nurse should:a. ask if she is allergic to bariumb. ask is she is allergic to shellfishc. give her a full glass of waterd. instruct her not to urinate until after the testANSWER B: Dye is injected intravenously for an IVP. The dye contains iodine. Allergy to shellfish often reflects iodine allergy and would therefore indicate that the client is at risk for an allergic reaction to the dye.

48. An adult has received one unit of packed red blood cells after sustaining severe trauma to his legs with profuse bleeding. To evaluate whether the transfusion has been effective the nurse should:a. take his blood pressureb. auscultate lung soundsc. check hemoglobin and hematocrit resultsd. take his temperatureANSWER C: Hemoglobin and hematocrit are expected to rise as a result of transfusion of packed red blood cells.

49. The nurse is administering tracheostomy care to an adult. Which of the following should be included in the procedure?a. soaking the outer cannula with saline solutionb. performing the procedure utilizing medical asepsisc. soaking the inner cannula in half-strength hydrogen peroxide solutiond. cutting a sterile gauze pad to place between the neck and the tracheostomy tubeANSWER C: The inner cannula is removed utilizing sterile gauze and is soaked in half-strength hydrogen peroxide solution. Clean the inner cannula with a small brush or pipe cleaners. Rinse instill saline or water and replace after the outer cannula has been suctioned.

50. Which of the following teaching should the nurse include when establishing a bowel-training regimen for a 62-year-old with chronic constipation?a. avoid laxativeb. decrease exercisec. increase the fiber content of your dietd. increase fluid intake 4500-5000 mlANSWER C: The purpose of a bowel training program is to manipulate factors within the person’s control (food and fluid intake, exercise, time for defecation) to produce the elimination of a soft formed stool at regular intervals. The increase of fiber in the diet as well as an increase of fluids to 2500 –3000 ml and an increase of exercise will help the effectiveness of a bowel training program.

51. The nurse answers the phone in the emergency room, a woman states that she has a nosebleed that has not stopped for the past two hours. The nurse tells her that she should come to the ER immediately but do which of the following first?a. put pressure on the bridge of the nose for 5 to 30 minutes, applying an icepack and sit with the head forwardb. apply heat to the bridge of the nose and do not eatc. sit with the head back and use a towel to blot blood drainaged. when blood is felt in the nose, lightly blow the nose into a tissueAnswer: A – The usual site of nosebleeding is the anterior portion of the nasal area. Applying pressure encourages coagulation of bleeding. Ice vasoconstricts vessels, thus decreasing bleeding, and putting the head forward facilitates any bleeding to drain out of the nose instead of draining into the stomach, causing nausea. Blowing the nose would dislodge any clot formation, which is not the desired outcome.

52. A male client has been diagnosed with chronic obstructive pulmonary disease (COPD) for the last 10 years. He continues to smoke 2 packs of cigarettes a day. He requires oxygen to perform his daily activities. Which of the following therapeutic management modalities is necessary?a. low flow of oxygen is usually orderedb. oxygen flow is adjusted to a higher level if shortness of breath occursc. petroleum jelly should be applied around the nares to prevent irritationd. oxygen flow rate is not a concern since he will feel better if the rate is highAnswer: A – Oxygen therapy is required if the client is unable to maintain a PaO2 >55 mm Hg or an oxygen saturation (O2Sat) of < 85% at rest. Oxygen (1-2 L) is given to relieve pulmonary hypertension and decrease load on the right side of the heart. It should be used continuously. High flow oxygen elevates the PaO2 to a level that removes breathing stimulus.

53. Mrs. X has been diagnosed with acute asthma. she has been admitted to the hospital and all of the following instructions to the nurse are correct, except:a. the head of the bed should be in the high position to facilitate drainage and breathingb. a cool and dry environment should be maintainedc. air conditioner filter should be changed oftend. oxygen should never be used as it could restrict airways moreAnswer: D – Elevating the head of the bed facilitates drainage of secretions. A cool and dry environment decreases swelling of mucous membranes, expanding airway diameter to increase the amount of oxygen intake. Air conditioner filters are changed to remove pollens and environmental factors that may initiate an acute episode.

54. A female patient has had a partial gastrectomy with a vagotomy and pyloroplasty today. She has a nasogastric tube in her nares connected to low intermittent suction. The nurse should take which of the following precautions?a. do not irrigate or reposition the NG tube because the stomach sutures can be rupturedb. always use wrist restraints to assure placement of NGTc. the NG tube should not be taped to the nosed. expect copious amount of bright red blood from the NG tube postoperativelyAnswer A: The nurse should not irrigate or move the NG tube because this might disrupt the internal stomach sutures. The tube should be taped to the nose. Copious amounts of bright red blood would indicate post-op bleeding, and the nurse should report this to the surgeon immediately. Wrist restraints when ordered by the physician are only used if the client is confused and is likely to pull on the tube. Wrist restraints will not assure placement of the tube.

55. A man complains of cramping abdominal pain. He has been diagnosed with acute diverticulitis. What nursing interventions are likely to be ordered?a. increase activity and regular diet as toleratedb. advise bed rest, clear liquids and meperidine (Demerol), 50 mg IM every 3-4 hours as needed c. use ice packs on the abdomen and place the client in the trendelenburg positiond. use a K-pad (a temperature controlled heating pad) on the abdomen and allow regular diet as toleratedAnswer B: The client should rest and decrease stimulation and irrigation to the bowel by limiting the diet to clear liquids. A regular diet is contraindicated during an acute episode of diverticulitis; the client should either have nothing by mouth or clear liquids. Acute diverticulitis is very painful, and the client should be offered analgesia such as meperidine (Demerol) every 3-4 hours. Neither an icepack nor a K-pad would provide adequate pain relief for acute diverticulitis.

56. has been diagnosed with esophageal varices. The physician notes there is active bleeding and orders the nurse to insert NG tube. The nurse should do which of the following?a. insert the NG tube immediatelyb. question the order because a varix might be perforated during insertionc. use copious amount of K-Y jelly to insert the NG tubed. refuse the order because a varix might be perforated during insertionAnswer D: The nurse is legally and ethically responsible to question and refuse an order that is unsafe. Inserting a NG tube in a client with esophageal varices that are bleeding could cause rupture of varices and life threatening hemorrhage. When a nurse refuses a physician’s order, it is best to briefly and calmly explain your concerns to the physician. The nursing supervisor, or immediate supervisor in your unit, should then be notified immediately of the situation. When a nurse carries out an order that is known to be life threatening to the client, the nurse is not legally protected by the fact that “the physician ordered it.” A nurse is judged by the “usual standard of care by a nurse in that situation.” In this case, the nurse should know that inserting a nasogastric tube in a client with bleeding varices could cause rupture of varices resulting in hemorrhage and death.

57. A 30-year-old patient has been diagnosed with folic acid deficiency. The client asks the nurse which foods are high in folic acid, and the nurse correctly responds:a. green leafy vegetables, organ meats, nuts and eggsb. fresh shrimp and oystersc. dried fruits and oatmeald. tofu and tunaAnswer A: The Nurse should encourage foods rich in B vitamins and stress proper ways to cook vegetables to preserve potency by using the microwave or boiling them in a small amounts of water.

58. Which of the following is an example of pica?a. a craving for sweets c. a craving for shellfishb. a craving for laundry starch and ice d. craving for picklesAnswer B: Pica is a craving for a nonfood item. This behavioral disturbance can result from a change in the neurological system altered by anemia.

59. An 82-year-old woman living in a long-term care facility develops urinary incontinence. After ruling out the presence of urinary retention or a urinary tract infection (UTI), the nurse should:a. establish a 3-hour prompted voiding scheduleb. insert a foley catheter or teach the client to self-catheterizec. restrict her fluid intake to 1500 ml/dayd. use adult diapers and change them frequentlyAnswer A: Research has shown that urinary incontinence can be decreased using a 3-hour prompted voiding schedule. Catheterization for the inconvenience of the staff is not indicated. Restricting the client’s fluids and using adult diapers can cause complications such as dehydration and impaired skin integrity.

60. Client education for the individual with gout includes:a. dietary instructions to limit meat, poultry, organ meats and alcoholb. dietary instructions to limit complex carbohydrates such as flat bread, rice and pastac. instructions for proper cast cared. signs and symptoms of compartment syndrome, a major complicationAnswer A : Treatment of gout includes dietary restrictions of high purine content foods such as meats, poultry, fish, yeast, certain vegetables, and limitation of alcohol intake.

61. When a client responds to a crisis situation or an acute injury, the sympathetic nervous system will respond in which of the following ways?a. it will increase blood flow to the abdominal organsb. it will decrease blood flow to the vital organsc. it will stimulate the adrenals to release epinephrineAnswer C: The Sympathetic nervous system prepares the body for emergency responses (fight or flight), increasing the heart rate and contractility, stimulating the adrenal medulla to release epinephrine and norepinephrine, increasing respiratory rate, increasing blood flow to the cardiorespiratory systems, decreasing blood flow to the non-priority organs, releasing red blood cells to increase oxygen carrying capacity of the blood and stimulating the liver to release glucose to provide more energy for the body in crisis.

62. During the clonic phase of a generalized seizure, you may expect to see:a. pupil dilatation, tachycardia and muscle spasmsb. bladder incontinence, elevated blood pressure and diaphoresisc. loss of consciousness, cessation of breathing and cyanosisd. contracted throat muscles, hyperventilation and salivationAnswer B: In the clonic phase of a seizure, hyperventilation and rapid synchronous muscle jerks occur. The client may bite his or her tongue, have bowel and bladder incontinence, have dilated pupils, tachycardia, diaphoresis, and salivate heavily. Hypertension may also be present.

63. The physician orders ice for the scrotum of a client diagnosed with epididymitis. The nurse correctly assumes that:a. ice slows circulation and decreases peripheral edemab. ice should be applied in intervals, not continuouslyc. ice is placed on the scrotum continuously until the physician orders otherwised. ice will not stop the pain, and it has a placebo effectAnswer B: Ice therapy needs to be removed from the scrotum every 15-20 minutes.

64. The best time for menstruating women to perform a breast self-examination is:a. right before the menstrual periodb. during the menstrual periodc. a few days after the menstrual periodd. 14 days after the menstrual periodAnswer C: A few days after the menstrual period, the breasts have the least amount of fluids and are less tender. This may improve the accuracy and comfort of self-examination.

65. Which of the following procedures is most effective for preventing hemolytic blood transfusion reactions?a. administer the blood through 5% dextrose in water (D5W)b. administration of a steroid prior to the transfusionc. careful identification of the client and the blood productd. using a leukocyte-poor filter during the transfusionAnswer C: Hemolytic transfusion reactions result from ABO incompatibility between the client’s and donor’s blood. Careful determination that the client is receiving the right unit of blood is vital to prevent these reactions. Blood should be administered through normal saline, not D5W. However, fluid choices are not related to hemolytic reactions. Administering a steroid and transfusing through leukocyte-poor filter helps prevent non-hemolytic reactions, not hemolytic reactions.

66. A superficial partial-thickness burn should heal in:a. one week c. six weeksb. three weeks d. two monthsAnswer A: Healing of superficial partial-thickness burns usually occurs within a week.

67. The setting that is most suitable for the treatment of a client with a full thickness burn is:a. admission to a burn unitb. admission to a medical unitc. treatment in an emergency room or ambulatory care settingd. home health careAnswer A: Full-thickness burns usually require hospitalization in a burn unit with comprehensive care by a burn team. The age of a client and the body area involved determine the need for emergency attention.

68. A full thickness burn would appear:a. red, as if client were sunburnedb. bright red and weeping fluidc. mottled without weeping fluidd. brown and leather-likeAnswer D: A full thickness burn appears white or brown and leather-like.

69. In a patient with full thickness burn of the face, the nurse must immediately address:a. airway management and hypovolemic shockb. moderate discomfort and minor fluid lossc. pain management with intravenous morphined. wound careAnswer A: Airway maintenance is a priority in a full-thickness burn of the face, as swelling may cause airway obstruction. The nurse must observe the client for tachypnea, anxiety, agitation, hoarseness, stridor, or wheezing as signs of respiratory distress. Fluid resuscitation requires intravenous lactated Ringer’s solution to be started in the ambulance or the emergency room. These burns usually require skin grafting, but this is not a priority in the emergency management period.

70. A full thickness burn of the face should heal in:a. one week c. six weeksb. three weeks d. monthsAnswer D: A long period of recovery would be expected with a full-thickness burn. These burns usually require skin grafting and are susceptible to infection. Plastic surgery may be needed during the rehabilitation phase.

71. If the client with psoriasis complains about pruritus, the nurse should suggest using:a. drying soaps or agentsb. hot water when bathingc. emollient lubricantsd. a towel to provide vigorous drying after bathingAnswer C: Applying lotions with emollients in a thin layer over the skin and a thick layer over plaques usually is helpful with psoriasis. Psoriasis is not curable and fluctuates between periods of exacerbation and remission. Avoiding sunburn, infections, extremes of temperature, drying soaps and stress are suggested ways to manage psoriasis.

72. You are supervising a student nurse giving an IM injection to a client with right hip arthroplasty. You will know the SN requires further instruction if she:a. administers the injection in the left deltoid muscleb. turns the client on her right hip to administer the injectionc. keeps the abduction pillow in place and turns the client 10 degrees to administer the injection on the unaffected sided. administers the injection after turning the client to her left thigh, keeping the abduction pillow in placeAnswer B: Since the most common complication of total joint replacement is dislocation, correct positioning is important. Turning the client on either side without keeping the abduction pillow in place could lead to dislocation of the new prosthesis.

73. You are assisting a client to choose a meal that follows his dietary orders of high calorie, high protein, decreased sodium, and low potassium. You will know the understands his dietary guidelines when he chooses:a. crab, beets and spinach, baked potato, and milkb. halibut, salad, rice, and instant coffeec. sirloin steak, salad, baked potato with butter, and chocolate ice creamd. salmon, rice, green beans, sourdough bread, coffee, and ice creamAnswer D: The best choice of meal is fish (not halibut or cod, both high in potassium), rice, and green beans. Bread and ice cream will add calories and protein. Instant coffee is high in potassium, and beets and spinach are high in sodium.

74. The best rationale for introducing your-self to a blind client and telling him exactly what you are doing is that these actions:a. illustrate the principle of open communicationb. decrease the client’s anxiety and fear of the unknownc. are the accepted procedure for beginning a nurse-client relationshipd. encourage and utilize clear communicationAnswer B: Blind clients become anxious when they hear someone enter the room without talking.

75. Sitting down at the client’s bedside to talk with the client with convey a sense of:a. sympathy c. empathyb. communication d. encouragementAnswer C: Nonverbal action conveys acceptance, openness to listen, and empathy. It assists the client to verbalize feelings.

76. While assessing a client who has orders for a hot-water bottle, heating pad, or hot compress, the first sign of possible thermal injury is:a. tingling sensation in the extremities c. edemab. redness in the are d. painAnswer B: Redness, or erythema, is the first sign of possible injury. This is an important observation to prevent a burn injury.

77. When charting the procedure for applying restraints to a client, you will include:a. what the client says about the restraintb. procedure for applying the restraintc. physician’s orders regarding the restraintd. condition of the extremity following applicationAnswer D: Evaluation of the effects of the restraint is important to chart. Procedure is not relevant and what the client says may or may not be appropriate. Physician orders are already charted so you would not chart them again.

78. To perform the skill “turning to the side-lying position,” you would lower the head of the bed, elevate bed to working height, move client to your side of the bed, and flex client’s knees. The next intervention, would be to:a. roll the client on his sideb. reposition clientc. place one hand on client’s hip and other on shoulderd. reposition client’s arms so they are not under his bodyAnswer B: Before rolling client on his side, your hands must be in the correct position to turn.

79. Your client insists on being discharged from the hospital against medical advice. From a legal standpoint, the most important nursing action is to:a. notify the supervisor and hospital administrationb. determine exactly why the client wants to leavec. put all appropriate forms in the client’s chart before he leaves the hospitald. request that the client sign the against medical advice (AMA) formAnswer D: All of the above actions would be appropriate to carry out. Legally, signing the Against Medical Advice (AMA) form is most important.

80. You are moving the client from the bed to a chair. The first appropriate intervention is to:a. dangle the client at his bedsideb. put nonslip shoes or slippers on client’s feetc. rock the client and pivotd. position client so that he is comfortableAnswer A: Before moving the client, dangling at the bedside is important. This procedure stabilizes the client and allows you time to assess whether he develops vertigo from a drop in blood pressure.

82. Your initial instruction to a client on the use of crutches to move upstairs should be to:a. start with crutches and the unaffected leg on the same levelb. start with crutches and the affected leg on the same levelc. place crutches on the step after the affected leg is moved up the staird. place crutches on the stair and then move the affected leg to the stairAnswer A: The crutches and unaffected leg start on the same level; then, the unaffected leg is moved to the step, followed by the crutches and affected leg.

83. When a client experiences a severe anaphylactic reaction to a medication, your initial action is to:a. start an IV c. place the client in a supine positionb. assess vital signs d. prepare equipment for intubationAnswer C: The shock position is necessary to maintain vital signs. The other interventions may be carried out, but are not initial actions.

84. If a blood transfusion reaction occurs, the first intervention is to:a. place the client in high-fowler’s positionb. call the physicianc. slow the rate of transfusion to “keep open” rated. shut off the transfusionAnswer D: If the nurse suspects an allergic reaction, the blood should be shut off immediately, then the physician should be notified and the client placed in a position to facilitate breathing.

85. The correct action for instilling eye drops is to instill the drops:a. at the outer canthus of the eyeb. over the conjunctivac. directly on the cornead. into the center of conjunctival sacAnswer D: drops instilled in the center of the sac will assist in distributing the medication over the entire surface of the conjunctiva and anterior eyeball.

86. Assessing a client for hypovolemic shock, the sign that you would expect to note if this complication occurs is:a. hypertension c. oliguriab. cyanosis d. tachypnea

Answer C: In shock, there is decreased blood volume through the kidneys. This is evidenced by a decrease in the amount of urine excreted. The body has numerous compensatory mechanisms that assist in keeping the blood pressure normal for a short time.

87. When evaluating the client’s understanding of a low potassium diet, you will know he understands if he tells you that he will avoid:a. pasta c. dry cerealb. raw apples d. french breadAnswer B: Raw apples are high in potassium, while white-enriched and French bread, dry cereal, and pasta are foods low in potassium.

88. Irrigating a nasogastric tube should be carried out using which one of the following protocols?a. gently instill 20 cc normal saline and then withdraw solutionb. instill 30 cc sterile water and then withdraw solutionc. instill 30 cc sterile saline, forcefully if necessary, and allow fluid to flow into basin for returnd. gently instill 20 cc sterile water and then allow fluid to flow into basin for returnAnswer A: Gentle pressure is necessary when irrigating a nasogastric tube to prevent damage to the stomach wall. Saline prevents electrolyte imbalance.

89. The morning of the second postoperative day, a female patient is to be ambulated. Your first intervention is to:a. get her up in a chairb. use a walker when getting her upc. have her put minimal weight on the affected sided. practice getting her out of bed by slightly flexing her lipsAnswer B: Postoperative hip replacement clients may get up the first day, but need to use a walker for balance. They should not bear any weight on the affected side or sit in a chair, flexing their hips. Positions with 60o to 90o flexion should be avoided.

90. You are assigned a client who has just had a nasogastric tube inserted postoperatively. During your evaluation of his status, you will check for:a. electrolyte imbalance c. ulcerative colitisb. gastric distention d. infectionAnswer A: Nasogastric intubation can lead to the complication of electrolyte imbalance because of removing the gastric contents by suctioning. Large amounts of sodium and potassium are lost though the suctioning and, if not replaced via IV fluids, can lead to serious electrolyte imbalance.

91. Before administering a nasogastric feeding, you aspirate the stomach contents and obtain 50 cc of residual. Your next action is to:a. discard aspirate and begin tube feedingb. replace aspirate and begin tube feedingc. discard aspirate and hold the tube feedingd. replace aspirate and hold the tube feedingAnswer B: the aspirate contains electrolytes and hydrochloric acid; therefore, it must be replaced to prevent an imbalance. With a residual of 50 cc, the usual action is to administer the tube feeding.

92. You are assigned to a client with a central vein IV infusing hyperalimentation solution. The most important nursing intervention is:a. preparing the next bottle of solution prior to useb. maintaining the exact amount of solution administered hourly by adjusting the flow ratec. checking urine specific gravity, sugar, and acetone every for hoursd. changing the IV filter and tubing with each bottle changeAnswer C: Checking the urine for glucose and acetone is essential to prevent a hyperosmolar condition. Insulin may have to be administered according to rainbow coverage. Notify physician for urine glucose over 2+ and positive acetone.

93. You have been assigned to a female patient who needs to have a sterile urine specimen sent to the laboratory for a culture and sensitivity. After inserting the catheter, you find that urine is not flowing. Your next action is to:a. remove the catheter, check the meatus, and reinsert the catheterb. obtain a new, larger sized catheter and insert itc. reassess if the catheter is in the vagina; if so, remove it and reinsert into meatusd. insert the catheter a little farther, wait a few seconds, and if urine does not flow, reassess placementAnswer D: Check if catheter is inserted for enough into urethra or if it is in vagina. If in vagina, leave in place as a landmark, obtain new sterile set-up, and insert new catheter.

94. When the urine begins to flow through catheter, your next action is to:a. inflate the catheter balloon with sterile waterb. place the catheter tip into the specimen containerc. connect the catheter into the drainage tubingd. place the catheter tip into the urine collection receptacle

Answer B: When urine begins to flow, the catheter tip is placed into the specimen container. When the specimen is collected, the catheter tip is placed into the collection receptacle until urine flow ceases.

95. Following application of a leg cast, you will first check the toes for:a. increase in temperature c. edemab. change in color d. movement

Answer B: A cast is rigid and used to maintain alignment. If it is too tight, it will press on blood vessels. The color of the toes will change first, then temperature, when blood supply is decreased. As the blood flow slows through the walls of the vessels, edema will occur.

96. The client is unable to feel you apply pressure on his toes and complains of tingling. These signs indicate:a. pressure on a nerve c. overmedication of an analgesicb. phantom pain syndrome d. improper alignment of the fracture

Answer A: Since the client cannot feel sensory stimuli, a blockage of the nerves between the central nervous system and the peripheral system would be indicated.

97. From your knowledge of the casting procedure, you understand that a wet cat should be:a. placed on a firm surface for the first few hoursb. handled only with the palms of the handsc. left alone to set for at least three hoursd. pelated to lessen chance of irritation to the client

Answer B: if a wet cast is handled with the fingers, indentations in the cast will occur. This can cause pressure on the skin and cause weakness in the cast.

Answer C: To prevent introduction of pathogens into the urinary tract, sterile equipment is used and its sterility maintained.

99. Care for a client following a bronchoscopy will include:a. withholding food and liquids until the gag reflex returnsb. providing throat irrigations every four hoursc. having the client refrain from talking for several daysd. suctioning frequently, as orderedAnswer A: Until the gag reflex returns, the client cannot handle foods or liquids, and may aspirate. Suctioning is not usually ordered.

100. Reviewing the lab tests of a client scheduled for surgery, you find that the white blood cell count is 9800/mm3. The most appropriate intervention is to:a. call the operating room and cancel the surgeryb. notify the surgeon immediatelyc. take on action as your recognize that it is a normal valued. call the lab and have the test repeated

Answer C: The normal WBC is 4500 to 11,000/cu mm. If the results were abnormally high, the surgeon would have to be notified and the surgery may be canceled. Tests with abnormal results are not routinely repeated unless the results are grossly abnormal.